Commercial Insurance Quotation Request Form

Date

Action Required

Client Details

Insured Name (required)

Name of the entity, e.g. company name, sole trader's legal name, etc.

Contact Name (required)

Email Address (required)

Phone Number

Occupation

Insured Situation

Interested Party

Previous Insurer

Inception / Expiry Date

Current /Previous Intermediary

Insurance History

Have you, your spouse, your partner or in the case of a company the Directors, either alone or conjointly through partnerships or Directorships in other companies:

(a) Ever had an insurance refused, cancelled , declined or had increased terms?

(b1) During the past five years - been declared bankrupt?

(b2) During the past five years - been convicted of a criminal offence?

(c) Sustained more than 6 losses or had claims totaling in all more than $10,000 in the past three years for those sections to be insured by this contract?

If Yes to any of above, please provide details:

Any other relevant information to disclose?

Property Details

Occupation of Premises

Age of Building

Wall Material

Roof Material

Floor Material

Water Supplied Sprinkling System

What percentage of the building(s) floor area is enclosed by or contains EPS or Insulated sandwich panelling

Hydrants & Hose Reels

Alarms & Smoke Detector

Extinguishers

If Yes, how many?

Other Protection

Hazardous Goods Storage

If Yes, please specify type of hazardous goods

If Yes, please specify quantity

Security Details

Deadlocks on all External Doors

Keylocks on all Windows

Bars/Grills on Windows

Local Alarm

Back to Base Alarm

Other, please specify

Broadform Public/Product Liability

Years in this Industry

Limit of Liability ($)

Good in Control ($)

Road Test Vehicles ($)

Number of Employees

Annual Wages ($)

Annual Turnover ($)

Type of Goods Manufactured

Product Liability

Estimated Turnover ($)

Product Liability

Details of Export (Where to)

Product Liability

Fire

Building ($)

Contents ($)

Stock ($)

Removal of Derbris ($)

Accidental Damage ($)

Others ($)

Total Insured in this section ($)

Burglary

Stock ($)

Ciggarettes / Tabacco / Liquor ($)

Contetns (Machines / Plant) ($)

Computers ($)

Damage to Premises ($)

Customer / Client's Goods ($)

Total Insured in this section ($)

Business Interruption

Gross Profit ($)

Increased Cost of Working ($)

Cost of Rewriting Records ($)

Loss of Rent ($)

Accounting Fee ($)

Indemnity Period

Total Insured in this section

Glass

External

Internal

Sign Writing ($)

Damage of Stock ($)

Money

In Transit ($)

On Premises B/H ($)

Residence ($)

In Safe / Strongroom ($)

On Premises Outside B/H ($)

Machniery Breakdown

Limit any one loss ($)

Deterioration of Stock ($)

Loss of Refrigerant

Electronic Equipment

Limit any one loss ($)

Restoration of Data ($)

Increased Cost of Working ($)

Cover

Services

Hurstville Head Office

Eastwood Office